Complications of laparoscopic surgery are different from those of conventional surgery. Laparoscopy seems to repair inguinal hernias with a lower rate of postoperative complications, especially to those related to surgical wound morbidity, infections or bleeding events, and postoperative surgical pain, but always these complications depend on the surgeon’s experience. Furthermore, the type and size of the hernia along with the patient’s conditions will also influence the presence of complications. On the other hand, most of intraoperative complications associated with this technique include complications due to the laparoscopic access, such as trocar injuries, although many specific complications related to the dissection of the area, mesh placement and fixation have also been described.
Laparoscopic surgery in inguinal hernia is associated to a complete change of the vision of the anatomy vs. conventional approach that adds technical difficulty, especially in the TEP (total extraperitoneal), where working space is limited and manoeuvres dissections are more complex.
In laparoscopic repair of inguinal hernias, there are two techniques well
differentiated: total extraperitoneal approach (TEP) and transabdominal preperitoneal approach (TAPP), the intraoperative complications of each of them are differents. For this reason, it is important to describe complications specifically related to each technique.
6.2 Intraoperative Complications Related to TEP
6.2.1 Complications Related to the Access to the Preperitoneal Space
These complications are frequent during the learning curve and may force conversion to an open surgical technique. One of the main steps of this technique includes the access to the preperitoneal space. Inadequate access may lead to conversion to TAPP or to open surgery.
Access to this space may be carried out by blunt dissection, assisted by the tip of the optic followed by dissection with one instrument after introduction of the first trocar, or using a balloon. A randomised, prospective, multicentre study showed that a dissection balloon made the dissection of the preperitoneal space easier and safer, thus reducing operative time, conversion rate and number of complications.
Complications related to access to the preperitoneal space include:
1. Problems related to epigastric vessels:
(a) Blunt dissection with the finger before introduction of the trocar could lead to a tear of the epigastric vessels, resulting in intense bleeding. To avoid bleeding, it is important to introduce the finger below the rectus muscle without doing any lateral movement.
(b) Another problem related to epigastric vessels includes dissection of the vessels from the anterior wall during dissection of the preperitoneal space, which makes surgery more difficult. It is important to perform a proper blunt dissection with the finger and to visualise the epigastric vessel through the balloon during insufflation, by introducing the optic inside of it, in order to guarantee that epigastric vessels are maintained attached to the anterior wall.
2. Problems related to balloon dissection: Besides the problems previously mentioned, bleeding of the epigastric vessels, peritoneal tears could also be related to balloon dissection. Smooth insufflation of the balloon is one of the main steps to avoid this problem. On the other hand, proper indications for
access and for the technique itself are other factors to avoid peritoneal tears. Patients with previous infraumbilical surgery could present fibrous tissue in this space with a difficult distension of the preperitoneal area. In this case, it is even more important to have slow and little dissection of the space with the balloon, continuing the dissection using scissors through the 5-mm trocar. In case of midline infraumbilical surgery, the incision for introduction of the balloon should be performed laterally to the incision, through the rectus muscle. In case of previous surgery in the preperitoneal space, such us prostatectomy, TAPP could be a better indication, although different authors, such as Dulucq et al., have shown that it is feasible. The last advice to avoid complications during balloon dissection include the recommendation of not to insufflate the balloon more than it is accepted, since it could blow up and make a massive tear of the peritoneum with the subsequent need to collect the different plastic parts of the balloon.
3. Visceral and vascular injuries: These complications could happen during insertion of trocars to perform surgery. Since there is no access to the abdominal cavity, visceral injuries due to introduction of trocars are very rare in this approach.
4. Bladder injuries: The most common visceral injury during TEP is related to injury of the bladder, while bowel injuries are uncommon, as trocars are inserted when the preperitoneal space is already created and under direct vision. Injury to the bladder has been reported in 8 of 3868 patients who underwent surgery during a 7.5-year period, the majority of whom had previously undergone suprapubic catheterisation. Laparoscopic peritoneal access or secondary suprapubic trocar placement can result in a bladder perforation, usually as result of failure to decompress a distended bladder. Less commonly, the injury is associated with a congenital bladder abnormality. Aspects to be considered to prevent or to treat this complication are:
(a) A proper indication of the hernia to be repaired is an important factor to avoid this complication. Those cases with previous surgery in the preperitoneal space, such as prostatectomy, could increase adhesions of the bladder in this space, increasing the possibility of having an injury, especially during the manoeuvres of dissection of the preperitoneal space. Bladder is especially prone to injury during laparoscopic inguinal hernia repair when the preperitoneal space has previously been dissected, e.g. previous preperitoneal hernia repair or prostatectomy. Incarcerated hernias could also be related to
these injuries, since the hernia sac is not yet reduced when the preperitoneal space is being created and a trocar may be inserted into the bladder. Based on this, correct indications for surgery are the best way to avoid this complication. Even though some authors have demonstrated good results with this approach in patients with previous prostatectomy, these hernias should be performed by TAPP approach, especially if surgeons are not experienced with this other technique.
(b) Special mention should be made to large direct or medial hernias, since the bladder can be a frequent content of this type of hernias and usually the sac is attached to the transversalis fascia when the space is created. On the other hand, caution must be taken when reducing this sac, as improper traction can result in injury.
(c) Another aspect to be considered is when hernia repair is performed in a patient with the bladder filled with urine. In this case, the bladder can decrease the preperitoneal space and trocars become more prone to injure the bladder. For this reason, it is recommended to have the patient emptying the bladder before going to operating room.
(d) This lesion shall be suspected if urine is withdrawn into a syringe after Veress needle insertion or if blood and gas are noticed in the urine drainage bag if the patient is catheterised. In questionable cases, methylene blue dye may be instilled into the bladder to look for leakage. Bladder injury recognised during laparoscopy shall be repaired laparoscopically, providing the experience of the surgeon is sufficient. This should be followed by bladder drainage for 7–10 days.
(e) Bladder injury may present in a delayed fashion with haematuria and lower abdominal discomfort. Contrast-enhanced computerised tomography, cystography, or cystoscopy are the primary imaging techniques used to evaluate patients for suspected injury. Small defects may be managed with postoperative decompression via an indwelling catheter for urinary drainage, whereas larger defects need repair.
5. Trocar site hernias: Hernias at trocar site are very rare after TEP for different
reasons: first reason is because assisting trocars are usually 5-mm trocars, and the second reason is that the 10–12-mm trocars just open the anterior fascia, maintaining the posterior fascia of the rectus muscle preserved.
6. Hypercapnia: This complication occurs during CO2 insufflation. The absorption of CO2 in the preperitoneal space is higher than intraperitoneally, being a factor to be considered when insufflation of CO2 happens in a virtual
space, especially preperitoneally. This complication is related in most cases to the learning curve, since longer intraoperative time can increase the absorption of CO2 by blood vessels of the preperitoneal space. Expert surgeons with short surgical time rarely see this complication, as it can be prevented by decreasing surgical time. On the other hand, the role of the anaesthesiologist is very important in order to monitor this situation.
7. Subcutaneous emphysema: This complication is common, but does not require any treatment, since CO2 is rapidly absorbed right after surgery.
6.2.2 Complications Related to the Dissection of the Hernia
1. Bowel injury: Studies on TEP and TAPP report intraoperative intestinal injury in 0–0.3 % of cases, with rates of 0–0.06 % in larger investigations involving over 1000 patients. Problems can arise if patients are not correctly placed in the Trendelenburg position. When this happens, the intestines can remain in the hernia sac, increasing the risk of thermal damage. Extraperitoneal laparoscopic surgery is performed under general anaesthesia with good muscle relaxation, otherwise the working space is too small and the bowel would be pushing the preperitoneal space, increasing the risk of injury. On the other hand, in case there is any gas leak, the preperitoneal space also becomes too small. For this reason, we use the balloon trocar to make the incision airtight.
2. Vascular injuries: In large investigations, involving over 1000 patients, the rates of injuries to great vessels are of 0–0.11 %. These vascular injuries may arise from injury to major vessels, to epigastric vessels, to vessels from the cord or to vessels surrounding Cooper’s ligament. During dissection, the surgeon must visualise an aspect of “spider’s web”, to indicate that he/she is in the right direction. Dissection must be blunt in order to decrease the possibility of an injury to the vessels of this space. During this dissection, the surgeon uses diathermy to control possible bleeding from small vessels. The bipolar method seems to be safer than the monopolar. Different situations, besides bleeding of epigastric vessels which have been previously described, are:
(a) At the high end of the dissection, there is always a small vessel, collateral of the inferior epigastric vessels. This vessel has to be coagulated with diathermy to prevent bleeding.
(b) The vas deferens is seen lying separately on the medial side, and the gonadal vessels are seen laterally, forming a triangle. This triangle, known as the “triangle of doom”, is bounded medially by the vans deferens, laterally by the gonadal vessels, with its apex at the internal inguinal ring, and the base is formed by the peritoneum. Dissection should be clear in this region, to avoid injury to the cord structures or iliac vessels.
(c) Bleeding from the vessels surrounding the area of the Cooper’s ligament might be difficult to control, being most of the time controlled with precise coagulation. In case of difficulty to control bleeding, the best methods to achieve a good haemostasis are to introduce gauze and to compress or to use some haemostatic agents.
(d) Injury to the major vessels can be fatal and usually requires urgent laparotomy and vascular repair.
3. Peritoneal tears: During dissection of the peritoneum, breaches in it can be found. Peritoneal tear is the most common reason for conversion and predisposes patients to small-bowel adhesions and internal herniation. The mesh will no longer be securely buttressed between the abdominal wall and retroperitoneum by intra-abdominal pressure and becomes susceptible to migrate if not stapled. Hence, closure of the defect is preferred. The following aspects must be considered:
(e) The presence of a previous mesh from a prior hernia repair presents a technical challenge for TAPP or TEP repairs of recurrence. The mesh from a prior Lichtenstein repair should not affect the field of a posterior approach. The best approach to a mesh placed during prior laparoscopic repairs may be to leave it in place, avoiding the risk of injury to the iliac vein or to the bladder. The new mesh can be laid on top of the old one to correct technical failures of a slipped or misplaced previously placed mesh. However, the mesh plug technique poses a unique problem for a laparoscopic repair of recurrence. The old plug creates an obstacle for dissection of the preperitoneal space, creating conditions to produce tears of it, and, on the other hand, can also be an obstacle to place the new mesh and to replace the peritoneum over it. Removal of the plug is not simple and cannot be easily accomplished with endo-shears. We find that electrocautery more effectively cuts the protruding aspect of the plug, thus allowing the possibility of posterior mesh placement and replacement and repair of the peritoneum. For this reason, the best approach for a recurrent hernia after plug technique is a
TAPP, since the peritoneum can be more easily dissected from the plug than using a TEP approach.
(f) The TEP technique must be meticulous and all peritoneum openings have to be closed to prevent postoperative occlusion. An Endoloop® is usually used to close those breaches in the peritoneum. If the peritoneal tear is near the arched line, the scope could be moved down, changing the 10-mm optic to a 5-mm one, to facilitate triangulation. If the closure is impossible, the surgeon should change to TAPP or to open procedure. If a pneumoperitoneum ensues, a Veress needle can be placed in the left hypochondrium to reduce it, increasing the space in the preperitoneal area. If there is doubt about a peritoneal breach, the procedure shall be completed with a laparoscopic exploration to investigate the pelvis. If there is a gap, it can be closed with sutures.
4. Difficult reduction of incarcerated hernias: In 2004, Ferzli et al. described their experience with TEP in repairing 11 acutely incarcerated inguinal hernias. Eight repairs were completed via TEP, and three converted to open repairs. They describe the use of various releasing incisions to free the incarcerated sac depending on the nature of the hernia (direct, indirect or femoral). This author reported no recurrences, a single mesh infection that resolved with continuous irrigation and a midline wound infection after bowel resection. In 2003, Tamme et al. showed their results in a large series of TEP repairs of inguinal hernias. In this group, they include, but does not detail, repairs performed on strangulated hernias. Their overall results demonstrated low rates of recurrence and complications. Amongst their conclusions, there is the statement that TEP is particularly advantageous for the treatment of bilateral, recurrent and strangulated hernias vs. open and TAPP repairs. They cite a reduction in postoperative neuralgia vs. open repair and a reduction in bowel injury and port site hernia vs. TAPP. Saggar and Sarang retrospectively looked at 34 patients (of 286 elective TEP hernia repairs) who underwent repair of chronically incarcerated inguinal hernia using TEP. Recurrence rate was higher for incarcerated vs. nonincarcerated hernias (5.8 vs. 0.35 %). Recurrences in the incarcerated group (n = 2) occurred during the immediate postoperative period and 2 months postoperatively. Scrotal haematoma and cord induration also were significantly higher in the incarcerated group. They converted the umbilical port to an intraperitoneal one to inspect the bowel when its viability was in question. Besides the good results published in repairing incarcerated hernias, TAPP seems to be the preferable option to repair these types of hernias, as
hernia contents are easily controlled with the intraperitoneal vision, the operation, in these cases, being, thus, safer.
5. Problems related to large sac: In a case of indirect hernia, lateral to the inferior epigastric vessels, the peritoneal sac is dissected away from cord structures, both medially and laterally until it is completely separated and then dealt with appropriately. At times, a long indirect sac cannot be completely reduced from the deep inguinal ring and is divided, with the peritoneal side being ligated with a laparoscopic suture. Laparoscopic repair of a scrotal hernia is a controversial subject in laparoscopy, because it implies a large abdominal wall defect and great difficulty in dissecting the extensive hernia sac. Literature on the subject is scant.
6.3 Postoperative Complications
1. Haematoma at the hernia site: Haematomas and seromas are most frequent complications, especially in the treatment of large indirect hernias (2–7 %). Usually they resolve spontaneously in about 6 weeks but may persist for several months. They do not represent a problem for the patient to return to normal activity but must be identified and not confused with possible recurrences. When in doubt, ultrasound and time will confirm the diagnosis (the haematoma decreases their size and hardens, leaving a well-defined mass, and is painless). Some authors recommend routine use of a drain, because the release of carbon dioxide pressure is followed by bleeding from tiny capillaries, resulting in an unpredictable amount of blood collecting in the preperitoneal space. Furthermore, drainage also ensures complete deflation and readaptation of the tissue layer. Avoidance of postoperative haematomas is important to the achievement of a low mesh infection rate and prevention of potential mesh displacement because of the collected fluid. Even though drains might be useful to control this complication, correct haemostasis is the best way to prevent it, since drains can be a factor that influence the postoperative course of patients, producing an uncomfortable sensation which can delay hospital leave. On the other hand, authors that use fibrin glue to fix the mesh include it on their list of advantages; using this method of fixation, the haemostatic effect of the fibrin sealant is added, and this can decrease the presence of haematomas and ecchymosis in the area, resulting in better postoperative outcomes.
2. Seroma: Seroma is a frequent complication of endoscopic total
extraperitoneal mesh repair of inguinal hernias, especially after a direct hernia, which may cause discomfort and anxiety. Its volume is proportional to the size of the preperitoneal “dead” space created after reduction of the hernia. Attempts to reduce its incidence after direct hernias have included tacking the transversalis fascia to the pubic ramus or closed suction drainage of the preperitoneal space. Both these techniques are not without problems. Primary closure of direct inguinal hernia defects with a pre-tied suture loop during endoscopic TEP repair is safe, efficient and very reliable for prevention of postoperative seroma formation, without increasing the risk of developing chronic groin pain or hernia recurrence. This technique should be the preferred method over stapling of transversalis fascia or insertion of a closed suction drainage device in such a situation.
3. Infection: Antibiotic prophylaxis in inguinal hernia surgery is controversial. Overall infection rate is low, with a mean value of 1–4 %. Infectious rate <2 % is regarded as a clean operation. Antibiotic prophylaxis may reduce wound infection rates with impact on patients’ satisfaction, wound care and sick leave, but it also involves risks of toxicity, allergic side effects, bacterial resistance and higher costs. There has been a discussion on risk factors used to select the best candidates for antibiotic prophylaxis. Age >75 years, obesity and urinary catheter were heavy risk factors for global infectious complications in one study. Other known risk factors for infectious complications are hernia recurrence, diabetes, immune suppressants, corticosteroid usage and malignancy. Until now, a total of 14 RCTs comparing antibiotic prophylaxis vs. placebo in inguinal hernia surgery were identified, of which there was only 1 about laparoscopic repair and the remaining 13 were about open repair. The endoscopic RCT by Schwetling and Bärlehner has an incorrect randomisation, lacks definition of wound infection and is heavily underpowered with only 40 patients in each arm. It does not allow any conclusions. For this reason, in other to avoid infection after TEP repair, the same protocol then after open inguinal hernia repair must be followed.
4. Chronic pain: Acute and chronic pain, defined as pain lasting for 3 months or more after inguinal hernia surgery, has emerged as a key issue in literature. Reported chronic pain rates after groin hernia repair vary from 0 to 75.5 %. Overall, moderate to severe pain was experienced by 10–12 % of patients. In this respect, operations performed endoscopically seem to be more favourable than both non-mesh and mesh open technique operations. A retrospective, multicentric comparison of 1972 TAPP and TEP hernia repairs using
polyester meshes found no difference in chronic pain with rates of 0.6 and 0.7
% after TAPP and TEP, respectively. A systematic review of Wake et al. comparing TAPP and TEP showed no difference in early and chronic pain. According to the existing literature, there is no difference in acute and chronic pain after TAPP and TEP hernia repair. After introduction of endoscopic hernia surgery, mesh fixation was thought to be mandatory to avoid dislocation of the mesh and recurrences. Permanent fixation with tackers, staples or sutures was used. The perplexing problem of chronic pain after endoscopic hernia surgery raised the question of whether fixation is really necessary. Nerve entrapment and pain caused by shrinkage of the mesh due to scar tissue formation have been suggested as possible causes. As it can be observed, factors involved in chronic pain after TEP repair are fixation and type of mesh:
(a) Fixation of mesh is typically performed to minimise risk of recurrence in laparoscopic inguinal hernia repair. Mesh fixation with staples has been implicated as a cause of chronic inguinal pain. Different studies have been performed to compare mesh fixation using fibrin sealant vs. staple fixation in laparoscopic inguinal hernia and to compare outcomes for hernia recurrence and chronic inguinal pain. Because fibrin glue mesh fixation in laparoscopic inguinal hernia repair achieves similar hernia recurrence rates compared with staple/tacker fixation, but decreased incidence of chronic inguinal pain, it may be the preferred technique. The technique of non-fixation or temporary fixation using glue is increasingly used to solve this pain problem
(b) On the other hand, meshes might also have an influence in chronic pain. The last meta-analysis conducted by A Currie et al. in surgical endoscopy has shown that lightweight and heavyweight mesh repair had similar outcomes with regard to postoperative pain, seroma development and time to return to work after TEP repair.
5. Nerve entrapment: No injuries have been reported of the ilioinguinal or iliohypogastric nerve. Neuralgia paraesthetica may be originated due to the dissection or due to the fact of placing a tacker in the femoral cutaneous nerve causing injury or in femoral branch of the genitofemoral nerve. Anatomical knowledge of the preperitoneal space prevents such injuries, as well as non-fixation or glue fixation, as mentioned previously. The location of the staple by radiology and laparoscopic removal may solve the problem.
6. Mesh-related complications:
(a) Migration of the mesh: This complication is related to insufficient fixation of the mesh to Cooper’s ligament or to the use of a small size of prosthesis. To avoid this, one should always check the correct mesh placement and size. On the other hand, tears of the peritoneum, in those cases in which the mesh is not fixed, can be also related to mesh migration.
(b) Infection: Rejection of the prosthesis, infection or retroperitoneal abscesses are rare. Recurrence does not usually happen if you need to remove the prosthesis.
(c) Mesh erosion to the bladder: Mesh erosion to the bladder after laparoscopic inguinal hernia repair is rare; only eight cases have been reported since 1994. Therefore, the exact incidence is not known. Both polypropylene and expanded polytetrafluoroethylene have been incriminated. Probable causes are unrecognised injury to the bladder wall at the time of the laparoscopic inguinal hernia repair and improper placement of mesh and fixation material. Repeated urinary tract infections, haematuria or the development of bladder stones can all be presenting signs.
(d) Adhesions and fistulas to intra-abdominal organs.
7. Bowel obstruction: This complication is caused by herniation of the small intestine through a peritoneal breach or by attachment of bowel to a missed peritoneal hole that could have enlarged in the postoperative period. Patients can go through laparoscopic revision, without need of intestinal resection. The risk of intestinal obstruction in the postoperative period is not more important for TEP than it is for Lichtenstein technique.
8. Bowel perforation: Perforations of small intestine in the postoperative period resulted from thermal injury during operation, and the symptoms manifest, usually, 5–8 days after surgery. During reoperation, by laparoscopy or laparotomy, there is no need to remove meshes, although local findings and the grade of the peritonitis can lead the surgeon to remove it.
9. Urinary complications: Urinary retention is less common after inguinal herniorrhaphies performed under local anaesthesia compared with general or regional one. However, this complication is more commonly related to spinal anaesthesia, which it is not usually used in laparoscopic approaches, but it also happens after general anaesthesia. The incidence varies widely from as low as 0.2 % in a single-author study from France to as high as 22.2 % of patients undergoing laparoscopic inguinal hernia repair in a study from Mayo Clinic in Rochester, Minnesota. More commonly, it is reported to occur in the
2–7 % range. Although reports in the literature conflict somewhat, in general older age, prostatic symptoms before surgery, postoperative use of narcotics and administration of postoperative intravenous fluid >500 cc have been found to be predictive. Type of procedure (TEP vs. TAPP), surgical time, anaesthesia time, intraoperative fluid restriction or development of other complications do not appear to be significant risk factors. In general, it can be avoided by restricting fluid intake, intraoperative and postoperative, and by early ambulation. If, after 8 h of surgery, the patient does not urinate spontaneously, bladder catheterisation shall be advised.
10. Testicular complications:
(a) Transient postoperative pain: It is usually a burning testicular sensation due to trauma of the genitofemoral nerve or of the testicular sympathetic nerves or, still, to cord oedema, especially in case of fenestration of the mesh. It occurs in 0.2 % of cases. The discomfort is usually transient and responds to elevation of the testicle and analgesics.
(b) Hydrocele: This complication appears in 1 % of the hernia repairs performed by laparoscopy, but the cause is not known. Whereas urological literature suggests that this is due to the practice of leaving the distal sac in situ, most experienced hernia surgeons do not accept this theory. Some authors propose that it occurs when an unrecognised vaginal process is blocked and the accumulated fluid cannot drain freely into the peritoneal cavity. It is important to differentiate hydrocele from seroma because the latter is almost always self-limiting and will resolve without treatment. The treatment is the same as for any other hydrocele.
(c) Scrotal haematomas: This complication can be prevented after laparoscopic inguinal hernia repair if complete haemostasis is assured before completing the procedure. Conservative treatment (ice, scrotal support, pain management and observation) is sufficient for most, although large haematomas may require surgical drainage. Patients with bleeding disorders are especially prone to this complication.
(d) Orchitis: It is defined as postoperative inflammation of the testicle occurring within 1–5 days after surgery. It is felt to be due to acute thrombosis of the delicate venous pampiniform plexus rather than arterial injury. It is most common after inguinal scrotal herniorrhaphy when extensive dissection of the spermatic cord has been performed. Presenting symptoms are low-grade fever with a painful and enlarged and firm testicle. The differential diagnosis includes
scrotal haematoma and testicular torsion. Management is supportive with scrotal support and anti-inflammatory agents. Duplex ultrasound scanning is useful when infarction is suspected. Ischaemic orchitis may result in testicular necrosis within days or have a slower course resulting in testicular atrophy during a period of several months. Fortunately, most patients recover from ischaemic orchitis uneventfully without testicular atrophy. Interestingly, most patients who develop testicular atrophy do not provide history of orchitis. It is not yet known whether laparoscopy will have any advantage over conventional surgery because of the more proximal dissection in the preperitoneal space. However, in one large analysis of a prospectively maintained database containing 8050 TAPP laparoscopic hernia repairs, orchitis and testicular atrophy were reported to be extremely low at 0.1 and 0.05 %, respectively. Interestingly, this group removes all indirect sacs, no matter their size, except in rare circumstances of excessive inflammation. Nevertheless, based primarily on the extensive writings of the late George Wantz, undue dissection of cord and testicle to remove an indirect inguinal hernia sac completely is not recommended. The hernia sac can be divided at a convenient point in the inguinal canal and has the distal aspect left open. The proximal sac is then dissected from the cord structures and ligated.
(e) Testicular atrophy: As it has been described, it is rare, even after injury of the spermatic vessels, due to the rich collateral circulation (0.3–0.5 % difference in classical surgery). Surgeon’s experience makes this injury very rare after the initial learning curve, but it can be further avoided by minimising dissection of the cord and leaving the distal segment of the indirect sac.
11. Sexual dysfunction and infertility: In patients with inguinal hernias, sexual activity may be impaired due to hernia-related pain. Surgical repair may improve these complaints but can also lead to similar symptoms as long-term complication of the operation. Injury to the vas deferens can occur during laparoscopic inguinal hernia repair and, if bilateral, will lead to certain infertility. The vas deferens may be injured during dissection and mobilisation or during fixation of the mesh. Unilateral injury to the vas can lead to exposure of spermatozoa to the immune system and the formation of antisperm antibodies, causing secondary infertility. Bilateral testicular atrophy (discussed earlier) is another cause. A recent study that detailed 14 patients whose infertility was, apparently, the result of damage to the spermatic cord caused by normal fibroplastic response to polypropylene mesh, resulting in obstruction of the vas deferens included 10 open procedures, 2 laparoscopic and 2 where laparoscopy was used on one side and open on the other. However, the explanation for their findings might be
a more traditional injury mechanism at time of surgery, such as ligation, division or cauterisation followed by scarring to the most convenient adjacent structure that, in this case, would be the mesh. Endoscopic hernia repair is associated with less postoperative pain and earlier return to normal activities, but its effect on pain-related sexual function has not been studied frequently. The study conducted by Schouten et al. shows that painful sexual activity is presented in one third of patients with inguinal hernias and is improved in the majority of patients following TEP hernia repair. Postoperatively, moderate to severe painful sexual activity occurred in 2.3 % of the patients with no history of preoperative complaints